Picking the Right Device w/ Dr. Joel Cohen

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "Picking the Right Device." Dr. Bass, we've talked about various devices in these podcast episodes. What's the idea behind this one?

Dr. Lawrence Bass (00:31):
There are multiple devices on the market designed to treat a given beauty condition, even multiple devices with specific FDA clearances for those conditions. Doctors do a lot of research and speak with multiple colleagues before purchasing a device to use in their practice. And then they spend time learning how to use those devices to best advantage once they get them. What can patients do to find the best devices? This is a much harder task put in practical terms. How should you approach finding your device care? What are the hot new devices that really represent progress?

Doreen Wu (01:14):
But before we dive into that topic, we have a special guest joining us today.

Dr. Lawrence Bass (01:19):
I'm happy to introduce my friend and colleague, Dr. Joel Cohen, who's a dermatologist in Denver, Colorado. Dr. Cohen is extremely involved and active in clinical research and lecturing and teaching about the latest advances in aesthetic dermatology.

Doreen Wu (01:39):
So Dr. Cohen, what are the big groups of devices and how would you break it down for us?

Dr. Joel Cohen (01:45):
So in our practice we have a lot of devices and as Larry indicated, some of these actually can treat the same conditions. But I like to really focus on devices that allow us to treat lines and wrinkles etched in the skin as well as scars, and then devices that allow us to treat pigmentation and then devices and procedures that allow us to treat areas of redness such as rosacea or telangiectasias.

Doreen Wu (02:13):
Do you have preferences within these different classes or does it depend on patient specific details?

Dr. Joel Cohen (02:19):
You know, I think that there are some really solid platforms that are out there that allow you to treat many of these conditions. And the Sciton platform, the Joule X is one of those. So with 1/2-20 plug, you can treat patients with a fractional blade of erbium called ProFractional. You can use full field erbium resurfacing, which is what I do a lot of and published a lot on, especially around the mouth and around the eyes, to really give patients huge results with oftentimes just one treatment. And then also it has the hybrid fractional called Halo, which combines non-ablative fractional on the bladed. Fractional has broadband light where you can treat on a stamping mode or you can treat on the new high intensity rapid output, the hero mode, which is in motion. And then there's single shot erbium and micro laser peel. So essentially by plugging the device in once into 1/2-20 plug, you can calibrate different hand pieces that you want to use. And it's a very efficient laser and a very popular laser in our practice such that we have two of them.

Doreen Wu (03:30):
That leads me to wonder, how do you evaluate patients for device treatments versus other options?

Dr. Joel Cohen (03:36):
So many of my patients come in asking specifically about an area such as lines and wrinkles around the mouth or the eyes. And in many cases those are the first areas that really date them. They're focusing in the mirror. So I always express to them that you really have to pick the right tool to the job. You can't use a neuromodulator like Dysport or Botox to treat lines that are already etched in the skin, such as around the mouth, their eyes. You really need to do something to help with effacing those lines and that would be laser resurfacing.

Dr. Lawrence Bass (04:11):
Yeah, I think that's a critically important point. You know, a lot of people have heard of some aesthetic treatment or another, or maybe their friend had it and they don't really understand exactly what the treatment is designed to accomplish. They kind of think it fixes everything. So it's really important to get the right tool for the right job, as you said. I think that's beautifully put. and I agree with you a hundred percent that one of the main features that it's essential for whatever aesthetic provider you work with to be able to address, is lines and wrinkles, because that's definitively an aging change. Leaving that behind, even if you fix something else, really doesn't leave you looking your best. And the ability to address that is just critically important for anybody who's trying to work in the area of facial rejuvenation.

Dr. Joel Cohen (05:16):
So the area around the mouth, I really divide things into three subtypes and I actually published a scale on this in dermatologic surgery. But for people who have prominent muscle around the mouth from the orbicularis oris muscle, but it has not imprinted those smokers lines yet, I think it's perfectly helpful to use a neuromodulator like Dysport or Botox to try to minimize that muscle from imprinting the lines. And I say minimize and not completely prevent because I think it's important to be realistic with people that we're not using high doses in the lower face. We're using very low precise dosing to really try to decrease some of the muscle bulk but not make the muscle not function, which can feel funny. If people have some lines that are etched in the skin but they're not deep and they're not numerous, then I think you can get into those lines in many cases with a filler.

(06:21):
And we all have our favorite fillers in terms of fine line fillers to get into those. But when people have really significant number of lines and they're deep and they're etched, then resurfacing really makes the most sense. And for those patients, I like to use full field erbium resurfacing. It's something where you can recognize your endpoint of pinpoint blading. I don't use epinephrine in my block around the mouth, so I can recognize that endpoint more clearly. And I really see a tremendous amount of improvement usually with just one treatment. Whereas fractional bladed of resurfacing may take multiple treatments and not still get to the point where you can get with full field erbium. And I think full field erbium is, is very different than CO2 in the fact that we can recognize our endpoint and it has more water binding coefficient. It doesn't go as deep and it hasn't been associated with that delayed pigment loss that we saw many years ago. I saw in my fellowship 20-something years ago from full field CO2.

Dr. Lawrence Bass (07:24):
Yeah, I mean, I've always been on the erbium side of things, not the CO2 side of things. And that perioral area, the lipstick bleed lines, full field is the way to go. It does involve short interval of recovery time, typically a raw period of about five to seven days depending on how aggressively you need to go. But compared to the cumulative recovery time of doing multiple fractional treatments and given the, the amount of improvement that's typically obtained, I think it's preferred to figure out how you can squeeze that into your schedule. Now I'm curious to hear, because there, you know, there's sort of been the introduction of some more superficial filler materials in the United States and likely a couple more coming. Does that tilt the scale a little bit in favor of the fillers or it does hasn't improved things enough to really change your initial stratification that you published in Derm Surge?

Dr. Joel Cohen (08:38):
I don't think it really changes the way that I presented that. I think where people have numerous lines, it's just not realistic that we can get into all those lines, especially if, you know, they are more deep and of different calibers in terms of the morphology of all those lines. But I do think that some of the fillers really have been a very significant advance in what we had before. So the most common filler that I use for the perioral lines is Restylane Kysse. I find it to have less swelling than many of the other products and I think it integrates into the skin really nicely and it's very common for me to use it not only into the lip substance, the mucosa and the red part of the lip, but also to some of the fine lines around the mouth. I think that the RHA Redensity product is also really nice product for etched lines around the mouth. But when patients again have numerous lines and it's just not realistic to fill all those areas, and in many cases there's textural change to the skin that we call actinic elastosis or sun damage type changes where you can't treat that with filler. And really that's where resurfacing comes into play.

Dr. Lawrence Bass (09:58):
And you get a durability of result. That filler is just never going to give you.

Dr. Joel Cohen (10:04):
Agree. And I do like to use neuromodulators to prevent patients from contracting the muscle in those exact spots which could recapitulate the lines and etch them over time. They're not going to go back to where they were at baseline, but I think it makes sense to see patients every four months or so for tiny little aliquots of Botox or Dysport or Jeaveau or Xeomin into the orbicularis oris muscle on the upper lip as well as on the lower lip. And to talk about the lower lip for a moment, you know, I always was much more aggressive on the upper lip than on the lower part of the lip. And at one point I asked a colleague and friend, Jason Pozner, to do OCT analysis of the characteristics and compare between the upper and the lower lip because he had that device and I have the pictures in my lecture.

(11:02):
And since then he really showed me that the lower lip and the mucosa changing over the vermilion border to the area be before you get to that little crease in the chin is very similar to the upper lip. So I now treat that very similarly between upper and lower lip. And I'm seeing better results in terms of the etch lines and wrinkles on the lower lip. And in addition, I've always treated the red part of the lower lip in our fair complected patients who have these etched lines on the entire area around the mouth because they're fair complected, they've had a lot of sun exposure to lead to some of those imprinting in the lines. And they do have skin changes we call actiniculitis and the lower lip in many cases, which is a pre-cancerous condition.

Dr. Lawrence Bass (11:51):
Yeah, that's an important point that resurfacing reduces the actinic burden and therefore your risk of skin cancer in addition to providing a cosmetic improvement. The point about neuromodulators is, is also important and illustrates how particularly as changes get more advanced, a multi-modality approach is usually going to get you to the most complete correction that's obtainable

Dr. Joel Cohen (12:21):
Agree. And I think, you know, when patients quote clinical trials or we talk to them about a trial that we may have done that's using monotherapy, we're using one tool to really look at the duration and the efficacy and the degree of improvement that patients get. But in real life, we're using our entire toolbox to try to get to patients to that point that they look at themselves in the mirror and they're happy with the improvement. And then it comes to a point where we talk about let's try to maintain that improvement. So from a resurfacing perspective, you know, I don't think it's reasonable that every few years somebody is going to want do a heavy full field erbium resurfacing and take a week or more in terms of the actual healing time. So after they've done that once, I like to do lower density fractional erbium or lower density fractional CO2 perhaps every six or eight months just to get them a little bit more improvement.

(13:21):
And I think that that's where things like microneedling can come into play to allow them that stimulation and new collagen formation. But one of the lasers that I'm really excited about is a new laser called the Acclaro laser. It's called UltraClear. And there are multiple modes on this laser. And the lightest mode is called the 3D miracle. And it really truly is a lunchtime procedure. Patients can come in to the office, take standardized photos, no anesthesia is actually required. Patients can have the treatment in as little as 10 to 15 minutes, and the discomfort is one out of 10. And I consider myself pretty wimpy and my wife would agree, and truly that is one out of 10 discomfort for me. So it really, it's not much more than just feeling the vibration and a little bit of heat on the skin.

(14:19):
And patients have a little stinging for a few hours and that's it. So they're pink and dry for about two days. So I've done the treatment on Friday night, I've gone out with people on Saturday night and they don't really realize unless I take my glasses off that I'm a little bit pink on the rest of my face and by Monday I look absolutely fine. So I think that that's important for people who want to do treatments but don't want a lot of downtime and understand that there'll be a cumulative effect and be people who've reached the endpoint that they want to, such as with full field orum resurfacing around the mountain eyes and they just want to continue that type of improvement.

Dr. Lawrence Bass (15:02):
Yeah, that points up another important concept with device, which is if you're doing an aggressive peel, as you said, you know, once maybe enough, and then some maintenance treatments down the line in the years ahead. But I'm in New York City, a lot of people have a crazy work schedule or a crazy social schedule or both, and they can't take the downtime. It's okay to proceed with other treatments and if you don't yet have pronounced aging changes, you may not need the bigger treatment that's recovery based. But a lot of the lighter treatments need to be done in a series.

(15:51):
And doing a treatment without doing the requisite number of typically required treatments is likely to get you a disappointing result. So a lot of the devices, particularly fractionated treatments, need to be used in a series and a maintenance fashion. If you don't do enough of them, you're predictably not going to get a meaningful result. So that's a really important part of understanding what you're getting into when you start with a treatment and going with some of that advice from your dermatologist or plastic surgeon who's going to advise you in their experience what's likely to be needed to get you where you're trying to go.

Dr. Joel Cohen (16:41):
So practicing in Denver, and we have patients that are still attorneys or people who are very visible and work for some of the big companies in the tech world or in some of the defense department world. So, you know, not everybody can take downtime throughout the year, but everybody takes vacation. And I think that it's realistic to say that for somebody who wants to see major improvement and may have some very significant social event on their radar in four to six months, like their daughter's wedding or something like that, they really need to pick the right tool for the job. And I really encourage those patients to come in. We'll do the resurfacing, they'll take at least a week, a week and a half off of work. They're usually re-epithelialized at that point and their skin is healed over and they may just have some pink and that's going to last several weeks.

(17:33):
And we try to give them a tinted sunscreen that is an effective sunscreen, but also a camouflage so that they can go back to work. So that seems to work for my patients and I do take care of a lot of patients who come here specifically for me to, to resurface and then they'll take vacation in the mountains. So some of these people live in California in the media world, and some people live in New York. And it's just, we make it work for them, but for the people that it just never seems to work. I think having alternatives like the lower density fractional CO2 or fractional erbium where you can heal up in probably about four days or a extended weekend is important. And those sequences of doing multiple treatment sessions is really critical to success.

Doreen Wu (18:22):
We've discussed many types of devices, their various modalities, their functions in the episode so far. I'm curious, where's the special sauce? Does it lie with the device or the provider?

Dr. Joel Cohen (18:34):
I think really seeing an experienced physician who has done a lot of resurfacing is critical to success. So Larry, as a plastic surgeon who's done a lot of erbium over the years, me as a dermatologist who's done a lot of erbium over the years, we both lecture on it at national and international meetings. We both publish on it. We're showing patients our results because showing patients pictures of what you might be able to accomplish that aren't yours, isn't really going to get patients to that point where they feel that they're seeing the right person. And that may not give them the results that they're looking for unless they are seeing the right person and really recognizing the endpoint and using and knowing how to use this equipment is really key to success.

Dr. Lawrence Bass (19:23):
Yeah, I agree with that completely. The devices have precision and very controlled parameters, and that's a virtue compared to a hand rendered process like a chemical peel where there's a lot of input and variability that can't be controlled to anything like the level of precision that a device has. The output from a laser when the settings are a certain way is going to only vary the tiniest amount. But selecting those parameters, applying them, applying them to the right person for the right reasons takes years of experience to learn. And that's brought to you by the provider. so finding someone who's willing to listen, who's going to customize the plan for you and knows how to apply these devices backwards and forwards is going to work heavily in your favor.

Doreen Wu (20:30):
And what do you think is the ideal setting for these treatments? In a med spa, a clinical office, or some other type of provider?

Dr. Joel Cohen (20:38):
No, I think when you're talking about big procedures like heavy resurfacing and ablated resurfacing, I'm most comfortable recommending this be done in a medical office. I think first of all, we do nerve blocks for these types of treatments. We oftentimes will have nitrous on hand to get people through the procedure and make them comfortable. I think it's really important to understand how to prep the patient and the different modalities that we use to prep patients. I've written a lot on that as well out of my academic department at University of California Irvine, even though I'm based in Colorado. And then finally really understanding what potentially can go wrong and having the ability to write a prescription for prophylactic antivirals, which is what we do, but also seeing patients in follow up and knowing when something may be going wrong, when to suspect something like infection and how to be able to treat that. So for all those reasons, I'm most comfortable with the ablative resurfacing, especially the heavier full field resurfacing being done in a medical office, and a physician who has used and trained on this type of device for a long time.

Dr. Lawrence Bass (21:54):
I think that all of that is right. And the other thing which I've talked about a lot on this podcast is this notion that this is medical care. Medical care is very safe, very predictable, but in the hands of someone who is properly trained as part of their residency training, as part of their specialty to perform a given treatment and who is watching what is going on the ability to coordinate a plan of care as well, rather than just render a certain product like a Botox injection or a BBL treatment with the pulse light is another important part of having an efficient beauty plan, a cost effective beauty plan, and one that gives you the results you're looking for.

Dr. Joel Cohen (22:54):
And I think it's very important for physicians to show patients their own results, show them their pictures, not the company's cherry picked pictures of the best case scenario, but show them multiple examples of your own work. Show them what the downtime looks like, what the final result can look like in a few different examples. And that's the best way to actually do things. And for a patient, I think it's important to ask, "how long have you been using this laser? How many treatments have you done in the past few years? How many treatments have you done in the past year, past month, past week?" to make sure somebody is truly comfortable using that device.

Doreen Wu (23:38):
Those are fantastic points. Lastly, before we conclude Dr. Bass, what should our listeners take away from today's episode?

Dr. Lawrence Bass (23:46):
In modern aesthetic medicine, there's a whole range of devices to address all of the common beauty needs in our face as we age. Selecting which device is right is a product of a consultative relationship with an expert provider, a dermatologist, a plastic surgeon, someone who's been trained to perform these treatments. It's important to plan for the recovery you need or understand what's going to be involved in the treatments, the number of treatments, the time course over which results are going to be obtained so that you're sure this is a good fit for you. And again, an experienced provider will work to customize something that's a good fit for you.

Doreen Wu (24:42):
Dr. Cohen, any takeaways you would like to add?

Dr. Joel Cohen (24:45):
I think that there's a lot of different modalities that we can use to help patients achieve their goals in improving lines and wrinkles. In many cases, to see more significant improvement, it's going to be lasers, but to see less, it may be things like chemical peels and it really depends on what the patient can do, what they can afford, and what their downtime is. But seeing an expert physician who performs these procedures all the time is really key. And then understanding that there are different densities. And sometimes when I see a patient and I recommend a procedure, they might say, you know, "I had a friend who had fractional CO2, or I had a friend that had the procedure you're talking about, and the downtime was too much." They don't realize that it's apples to oranges comparisons. We are in control of the density that we can treat, which is the percent coverage, and we could modulate that to be more specific to usually the downtime that a patient can do. So you can modulate it to maybe be a range of just a few days versus a heavier range of a week.

Doreen Wu (25:51):
Thank you, Dr. Cohen, Dr. Bass, for sharing your perspectives and expertise on this often pondered topic.

Dr. Lawrence Bass (25:57):
And I'll add my thank you to Dr. Cohen. I think this was an outstanding perspective on what's going on with devices and how to apply them to best advantage from someone who's truly an expert in the area.

Dr. Joel Cohen (26:11):
Thank you, Larry. I appreciate it. It's a pleasure to join you all.

Doreen Wu (26:15):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at podcast@drbass.net or DM us on Instagram, @drbassnyc.